On-line Comment Card

UConn Counseling and Mental Health Services is committed to continuous improvement, so we appreciate and value your feedback! Please let us know about your experience by completing the information below or give our CMHS Director, Dr. Elizabeth Cracco a call at 860.486.4705. Please do not include any confidential information, appointment requests or prescription refill requests. This form is not intended for clinically related requests surrounding your care or your medical records. This is not intended as a secure form for sending medical information. We look forward to hearing your comments, concerns, and suggestions for improvement.

Date of Visit

Time of Arrival at Counseling and Mental Health Services

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MM

Type of Visit

Appointment

Walk-in

Other

Not Applicable

Name

FirstLast

Peoplesoft # or Net ID

Phone

Email

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